Parent Newborn Nursing N30010 Summer 2001 Postpartum Case Study

1. Parent Newborn NursingN30010Summer 2001Postpartum Case Study Angeline Barbato Ashley O’Neal Tricia Neff

2. Patient History • Patient Name: K.M. • Age: 19 years old • Type of Delivery: Vaginal • Anesthesia: Epidural • Infant Gender: Female • Infant Feeding: Bottle • Reason for Admission: Post date induction • Allergies: NKDA

3. History (continued) • Work: Unemployed • Smoker: Smokes 1-2 cigarettes q 2 weeks • Alcohol use: Occasional • Substance Abuse: None • Factors affecting recovery: Smoking, low SES • Developmental Level: Late Adolescence • Significant Family History: None • Medical or Surgical History: None

4. Pregnancies: G1 P1 Delivery route: vaginal Anesthesia: Epidural LMP: 9-22-09 EDD: 6-29-10 Delivery Date: 7/7/10 Gestation: 41 weeks and 1 day Complications during Pregnancy: Post term Labor Medications During Pregnancy: Prenatabs OBN Oral 1 tab po daily (Multivitamin) OB/Gynecologic Hx

5. OB/Gynecologic Hx (continued) • STIs: None • GYN Disorders or Surgeries: None • Prenatal Classes: None • Diet Limitations: None

6. Prenatal Data:Laboratory Data

7. Diagnostic tests Antepartum Medications

8. Labor and Delivery Data • Type of delivery: Vaginal • Labor Onset: 7-6-10 at 0211 • Date of delivery: 7-7-10 at 0011 • Management in labor: Epidural; Induction due to post dates

9. Intrapartum Medications

10. Intrapartum Meds (continued)

11. Nursing Diagnoses for Labor and Delivery • Risk for sudden infant death syndromer/t increased vulnerability as evidence by maternal cigarette smoking • Goal:The caregiver will demonstrate an understanding of risk factors for sudden infant death syndrome and ways to prevent them by discharge. • Interventions: • Provide the patient with written materials providing information on positioning the infant on her back while sleeping • Eliminate smoking in the home and near the infant • Teach mother to assess infants color and breathing patterns • Instruct mother to avoid soft bedding and placing pillows and stuffed animals in the infants crib • Evaluation: At the end of our shift, the patient was able to verbalize risks associated with SIDS and the patient was able to demonstrate the proper way to position her baby for sleep. She was able to verbalize common signs of impaired breathing.

12. Nursing Diagnoses (continued) • Risk for disturbed body imager/t changes in appearance associated with pregnancy as evident by weight gain. • Goal: The client will verbalize and demonstrate acceptance of appearance and implement coping patterns during hospitalization. • Interventions: • Encourage client to express feelings, especially about the way she feels, thinks, or views herself. • Prepare client and significant other for physical and emotional changes. • Encourage visits from peers and significant others • Use therapeutic touch with client’s consent and provide privacy in a safe environment. • Evaluation: At the end of our shift, the client was able to verbalize appropriate expectations of her body returning to her pre-pregnancy state.

13. Nursing Diagnoses (continued) • Readiness for enhanced knowledger/t recent birth of infant as evidence by expression of interest in learning infant care. • Goal:The client will express understanding of knowledge of appropriate newborn care by discharge. • Interventions: • Teach appropriate umbilical cord care techniques. • Provide information about shaken baby syndrome. • Teach client about infant feeding schedules, positioning, and proper techniques. • Teach importance of infant immunization. • Evaluation:At the end of our shift, the client verbalized an understanding of knowledge for cord care, shaken baby syndrome, infant nutrition, and infant immunization.

14. Postpartum Data • B- breasts soft and non-tender to palpation • U- fundus firm, midline, 3 fingerbreadths below umbilicus. • B- voiding adequately with no pain or difficulties • B- bowel sounds active X4, last bowel movement 7-8-10 • L- light amount of lochia rubra • E- perineum showed no edema or ecchymosis; small hemorrhoid was present; bilateral labial lacerations without repair—pt stated hemorrhoid and lacerations were painless

15. Postpartum Data (continued) • H- pt denies pain and tenderness in bilat lower legs and calves; pedal pulses equal bilaterally • E- patient was in good spirits and in “taking-in" stage • B- bonded well with baby—talked to baby; held baby

16. Postpartum Medications • Motrin 600mg orally, every 6 hours as need for mild pain • Indications: mild to moderate pain or dysmenorrheal, inflammatory disorders including rheumatoid arthritis and osteoarthritis; lowering the fever • Side effects: HA; dizziness; drowsiness; psychic disturbances; blurred vision; tinnitus; arrhythmias; edema; GI bleeding; constipation; N/V; abdominal discomfort • Nursing responsibilities: assess pain prior to and 1-2 hours following admin; monitor temp and note signs associated with fever such as diaphoresis, tachycardia, and malaise • Darvocet 1-2 tabs orally, every 4 hours as needed for moderate to severe pain • Indications: decrease in moderate to severe pain • Side effects: dizziness; weakness; disorientation; HA; insomnia; blurred vision; sedation; hypotension; N/V; abdominal pain • Nursing responsibilities: assess pain prior to and 1-2 hours following admin; monitor vital signs; assess bowel function periodically

17. Newborn History • Weight: 6 lbs 9 oz. • Vital Signs: Apical 125bpm; Resp 45; Temp 37.1 • Length: 49 cm • Head circumference: 33cm • Blood sugar: 97mg/dL • Assessment:lung sounds clear in all fields, skin warm, dry and intact, bowel sounds active in all four quadrants; neurological reflexes present (babinksi, moro, sucking, palmer grasp, and rooting); umbilical cord black and drying; vagina and anus visible and patent; normal pitched cry • Lab tests:negative for PKU and passed hearing test

18. Newborn Medications • Erythromycin: ophthalmic 5mg/1Gm • Indications: infections caused by susceptible organisms • Side effects: sensitivity reactions that cause edema and inflammation; usually disappear within 24-48 hours • Vitamin K: IM injection, 0.5-1mg • Indications: promote blood coagulation • Side effects: pain and swelling at injection site; rash may become present • Nursing responsibilities: monitor for side effects and adverse reactions • Hepatitis B vaccine: 5mcg given IM • Indications: prevents Hepatitis B infection by providing passive immunity. • Side effects: rashes; erythema at IM site, pain, swelling, tenderness • Nursing responsibilities: assess for signs of anaphylaxis

19. Newborn Diagnoses • Risk for ineffective thermoregulationr/t newborn transition to extrauterine environment. • Goal: Infant will have a temperature between 36.5° C and 37.5° C and the parent will explain techniques to avoid heat loss at home. • Interventions: • Teach parent that when bathing her baby, provide a warm environment. • Teach the mother to avoid drafts and to keep the baby bundled. • Assess axillary temperature every four hours. • Teach the mother the proper way to assess the infant’s temperature. • Evaluation: Throughout our shift, the infant’s temperature remained within36.5° C and 37.5° C and the parent demonstrated an understanding of knowledge to avoid infant heat loss at home.